Monthly Archives: May 2017

Over the last 20 to 30 years we have all witnessed an increasing emphasis on “suicide prevention”. This has included TV spots, public health announcements, and the development of crisis lines. Most major emergency departments now have some form of mental health team available to them. Many police departments now have mental health teams, psychiatric nurses, or social workers working with them. All doctors, mental health workers, school counselors, school nurses have been encouraged to ask the question. The phrase “suicide ideation” has become part of our popular jargon.

Fair enough. Though some suicides result from competent and rational choices to end one’s suffering from incurable disease, many others are tragic, tragic both to the victim and his or her survivors. And it always seems even more tragic when the victim is young and the suicide unexpected or unfathomable.

One of the obvious results of this heightened awareness of suicide, “suicide ideation”, and the behaviours that are called “suicide attempts”, has been a dramatic increase in the numbers of people seen in emergency departments for the identified problem of “suicide ideation.”

Below are four graphs showing just how dramatic this increase has been. An increase of 11 to 14 percent per year for six years is quite astonishing. These are American figures but I am sure the trend would be the same in Canada.

Now, at first glance this would imply that the new “awareness” and alertness with regard to suicide, and especially suicide ideation, is working. It means, doesn’t it, that far more people are being identified as “at risk” and coming to, or being brought for, an emergency assessment. Which in turn would mean that the actual suicide rate should be declining.

But it isn’t.

The suicide rate in Canada for the years 1950 to 1960 averaged about 7.5 deaths per 100,000 people.

The suicide rate in Canada for the years 2000 to 2009 averaged about 12 deaths per 100,000 people.

In the United States the suicide rate increased 24% between 1999 and 2014 to 13 deaths per 100,000.

I cannot scientifically claim there is a cause-effect relationship here, only an association, but I can certainly claim that the awareness of and the alertness to “suicidal ideation” has NOT decreased the rate of actual suicide in any age group.

But I do think that by focusing on, advertising, talking relentlessly about, “suicidal ideation” we have dramatically increased the use of “suicidal thinking” and suicidal threats as interpersonal negotiating tools, while making no difference to, and certainly not preventing, actual suicides.

What we have been doing is not working. It may even be exacerbating the problem. Yet every month or two I hear more of the same being promoted. We have not reduced, we may even have increased, the incidence of the very personal and often tragic act of suicide. And we may have simply caused or grown another public health problem unnecessarily straining our resources.

After the Manchester bombing I read some articles in which the authors despaired of ever understanding any suicide bomber, any killer of “innocent children”. (I don’t know why we need the modifier ‘innocent’ in front of the word ‘children’, other than to imply there might be some not-so-innocent children it would be all right to kill.)

I often write to understand, a way of thinking things through carefully and with a degree of logic, using what we all know about these events and what we know about human behaviour. The following is what I arrived at. I do not know if this helps in any way, but here it is:

What are the layers of the pyramid that lead to an act of terror, especially an act of suicide terror, whether the weapon be a truck, a gun, or a bomb?

A mind experiment reveals the foundation of the pyramid: Imagine a group of 18 year-old boys (make that 16 to 23 years old if you will) being taken by their teacher to a small museum filled with artifacts. Once there the teacher tells the boys they have two choices. They can choose an artifact and the culture surrounding that artifact, spend the entire day studying it, and write a five page essay about it in the evening to be handed in the next day – or – they can each take up one of these baseball bats and spend an hour smashing the artifacts and then go for a beer in the nearest pub.

If need be we can refine this experiment by removing one or two of the most successful young men (academic, social, sexual, vocational) and by having the teacher demonstrate use of the bat on one of the artifacts.

I am not betting on the survival of the artifacts.

There is a developmental phase in the lives of young men when most experience some anger. Most put at least one fist hole in the dry wall before this passes. They are now quite suddenly responsible for their own futures; they are faced with years of unrewarding industry; it is now up to them to plan and organize and work if they are to eat, sleep under a roof, own a car, win the mating contest. And they must do this while watching it, seemingly, come so easily to others.

And this is new to homo sapiens – this span of adolescence reaching into the mid twenties. Until these last few generations most 16 to 23 year old boys were quickly embedded into a life of work, survival, training, routine. Just this morning there was recognition of this in the local paper with a proposal that boys in care be supported until age 25.

In his immature and random use of language Donald Trump may have actually been partially accurate when he recently called the Manchester bombers “losers”. I think he meant it as a school yard epithet with the modifier “evil” added, but within that pyramid of angry young men mentioned above, some are successful, some are struggling, and some perceive themselves as unjustly losing in the academic, social, vocational, sexual competitions.

So on this second level of the pyramid we find angry young men who perceive themselves as losing, unjustly losing.

We have to assume family has an influence here, though it seems suicide bombers are the progeny of both extremist angry fathers, and of fathers who are moderate in their religious beliefs. But we also know that the two psychological states by which boys react to their fathers is by either (sometimes both) imitation or opposition. Family then provides a third level of influence, though not necessarily as direct promulgation of extremist views.

But these are boys looking for direction, seeking answers for their disappointments and rage. They are also seeking simple answers to reduce their existential anxiety. So they easily fall prey to mesmerizing leaders, gurus, exhortations to violence. This can be an Imam at the local mosque, or a Youtube video or an extremist or racist website. The general source of their distress and their failures is made clear to them. This is the fourth level, a powerful influence in the form of an older man, a guru, a man with explanations and answers. A man, or group, who can point this angry and failing young man to a cause for his dissatisfaction and disaffection.

But this must be combined with some social isolation, a retreat from social influences that would otherwise undermine or counter the influences of the newly acquired “teacher”. And most friends or acquaintances interviewed after a suicide attack report something like, “He was always a little quiet, but I haven’t seen him for the last five or six months. He stopped coming to our….” And some do report a change of behavior such as an angry confrontation at the Mosque before they stop coming or are banished.

So now we have a fifth level: withdrawal from alternative social forces.

There would be a division at this point in the development: Those who end up being called a “lone wolf” because they act alone, and those who become part of a network.

The former, the lone wolf, is truly suicidal, and probably suffers from, by now, a psychotic depression (depressed and delusional). This person would have been in trouble before, perhaps summarily discharged, fired, or known to mental health services and local police. His attack will be one of rage with suicidal intent. The creed of groups like ISIS or the white supremacists simply give this person a final excuse and a sheen of righteousness. His weapon will be whatever is available to him. His target may be personally symbolic to him: People enjoying and celebrating when he cannot. Women who have spurned him. Gays who enticed him. A corporation that fired him. An army that excluded him. The group that gives him that “sheen of righteousness” could be white supremacists, fascists, extreme Islam, anti-Semites, or even, today, talk radio and Donald Trump.

The latter, the suicide bomber who uses a more sophisticated weapon crafted by others in a network, is the dupe. He is the youngest, weakest, of the group. He has been gradually pressured and convinced to carry this out. Though he may be a believer in the creed, and though he may also believe in the rewards of martyrdom promised, he is really doing this to please, to not disappoint his cult leaders and be cast out. These leaders may include an older brother, an uncle, a father. Or they are strangers who have become his family. To retain his position with them, at least in his imagination, he must carry out the act. They are the ones with the political agenda and the level of sociopathy required to inure them to the consequences.

As social scientists point out, it is a prime directive for homo sapiens to maintain standing in their community (power, pecking order, value); it is not a prime directive to listen to reason and apply educated perceptual and deductive processes to arrive at a truth. Hence the amazing displays of twisting, selecting, avoiding, diverting, and denial coming from Republican law makers when asked to comment on a particularly stupid, childish or even incriminating comment by Donald Trump.

In the Hans Christian Andersen story it is only a child who is free to blurt out, “But the emperor has no clothes.” The lords, the noblemen, the ladies, the merchants – they all have much to lose. As does the emperor himself.

This emperor, The Donald, likewise has much to lose should he ever admit either ignorance or failure. His whole narcissistic edifice would crumble. He would find himself staring at a reality he has never allowed himself to see before.

And perhaps some of those Republicans do not have law degrees or other marketable skills, and rely on their Government salaries to support five children, an invalid wife, two aging parents, and a large mortgage. These I forgive. They should keep their heads down and avoid microphones. But there are others I am sure who have many options. They would lose but the ephemeral status of a title and invitations to the old boys club.

Yet none speak up.

It is disappointing to learn that in an old democracy an incompetent man can be elected President on the basis of misdirected anger, show business glitz, and ridiculous promises, all flavored with misogyny and racism.

But it is more disappointing to see that not one nobleman, not one lawmaker, is able to overcome the prime directive from our days in the jungle – not one has the courage to put his standing in his community at risk and announce, as the child would, “The emperor has no clothes. The emperor is lying. The emperor is incompetent. I can no longer support the emperor. I resign.”

In November of 2016 I wrote the piece that follows. Predictions for the Trump Presidency. As Donald himself might say, “Who knew impeachment was so complicated?” So, I got that wrong. It will be a long and messy process. If only they had a parliamentary system and could simply call for a vote of non-confidence.

And I did not guess the extent to which Trump would incriminate himself with both his careless tweets and his loose boastful talk in both the Russia affair and the obstruction of investigation into the Russia affair.

Other than that though, my predictions are depressingly accurate. And I still think the danger for the U. S. of A. and the rest of the world is that Donald Trump, unlike Nixon, will not go gentle into that good night. The sane and rational leaders of America need a plan. As the bad news mounts; when Trump’s counter attacks and deflections begin to fail; when he is cornered, he will lash out. They must make sure he cannot bring the temple down.

Donald Trump has neither the knowledge nor patience to figure out how to repeal parts of Obamacare, renegotiate NAFTA, build a great wall, prosecute Hillary, create the mechanisms to actually find and deport 3 million immigrants, or even change the tax system.

He won’t interfere much with climate change accords, because he doesn’t really care one way or the other and this is also a very complicated endeavor. He will continue to contradict himself from day to day, responding to his immediate impulses and his (I must admit) well honed intuitions about his public.

He can interfere with the TPP because all he has to say is, “Not gonna do it.” China can take the lead and a trade deal will be struck with all countries on the Pacific excluding the USA. I have no idea what that means for the USA or Canada.

Anything that requires a great deal of work, attention to detail, building a consensus, formulating a complex plan, he will not do.

The bad news:

Within a few weeks of his presidency Donald Trump will manage to mix his business dealings, his self-aggrandizement, and his petty peeves with his presidency, with his representation of the people of the United States, to such a degree that the democrats and a few republicans will start an impeachment process. In the ensuing hearings his business dealings around the world and at home will be exposed. He will respond with anger and outrageous accusations. This will convince others to support the impeachment.

As it becomes clear that Donald J. Trump will be successfully impeached he will become a raging bull. He will not simply announce, “I am not a crook.” and board the helicopter in disgrace. He will rage. He will suffer an extreme blow to his narcissism. He will rage and lash out.

This will fuel the racist fires at home and cause great anxiety abroad. He could well bring the temple down.

Sane American leaders need to be thinking about a contingency plan.

Perhaps the fully sane leaders of the rest of the world could form a club and plan a contingency of their own. What to do when King Donald goes mad.

The first is the obvious. For God’s sake just adopt the Government single payer option. Join the rest of the advanced nations. It is cheaper. It is better. Per person you already pay more in taxes to support your limited medicare and all the other complicated subsidies than we in Canada pay for the whole shebang. We are healthier. And it would free up a lot of administrators, accountants, politicians, and lawyers to do something useful.

The second was a little more subtle. All this exhausting time and energy arguing about, and designing, some polyglot public/private health care system is really not about health. It’s about an insurance scheme that will pay doctors and hospitals for medical fixing of acute illnesses and accidents. Medical fixing is just a part of being and staying healthy.

If you could settle on a single payer option then much of that time, energy, administrative overload could be better used to address health in all its complexities: prevention, social determinants, secondary prevention, tertiary prevention, maintenance, management of chronic illness, diet, obesity, lifestyle, addictions, mental health….. at the moment a kid with Cystic Fibrosis in Canada will outlive her counterpart in the US by 10 years.

There is one other aspect to the current American “health care system” of which I have lately become more aware. While the main concern remains large segments of the American population receiving no medical care apart from Emergency visits, or able to afford only partial treatment of acute and chronic illnesses, there is another side to this coin:

Over investigation and over treatment for those who can afford “the best”. Your celebrities often get shitty medical care, from Marilyn Monroe, to Michael Jackson to Prince to, apparently, Donald J. Trump. This is also true of many of your highly specialized for profit residential treatment facilities. Many offer some real medicine mixed with a lot of flimflam, with length of stay and investigations determined by the money available.

For Profit has no business in medical investigation or treatment. Inevitably it means many will do without and many will get too much. And the burden, ultimately, still falls on the taxpayer.

Insane Consequences How the Mental Health Industry Fails the Mentally Ill by US advocate, DJ Jaffe is a tremendous resource for anyone wishing to understand the industry that has developed around mental illness. And that is an industry that ignores the most seriously ill in favour of promulgating programs that are not evidence based, that are grounded in social theory rather than scientific theory, and generate jobs for the professional carers.

I am absolutely amazed at the amount of work that has gone into this volume. If anyone doubts Jaffe’s conclusions or statements, his sources are well laid out so you can check on them for yourself. A great deal of the problems with mental illness treatment in the US is its totally absurd health care system which baffles those of us who live in countries with universal single payer health care.

A few years ago, the Bridgeross author, Erin Hawkes (When Quietness Came: A Neuroscientist’s Personal Journey with Schizophrenia), appeared on an NPR radio show in Ohio to talk about her book. The interviewer was amazed at how much care and treatment she received in both Halifax and then Vancouver. How much did it all cost, she was asked. She thought for quite awhile and said, “I think I once paid for an ambulance ride”. The interviewer was stunned.

But then, we don’t have absurd rules like the Institute for Mental Disease (IMD) exclusion. Because of this rule, Jaffe points out, Medicaid will not reimburse states for psychiatric beds. When the states cannot get reimbursed, they close the hospitals.

However, despite the difference in how health care is funded, most of what Jaffe talks about is relevant for Canada and, I suspect, other western countries. The seriously mentally ill are ignored for the most part, make up a huge proportion of the homeless and of the prison population. The focus, as Jaffe discusses, in the US and in other countries is on stigma which helps no one, on denying the connection with violence for those who are untreated, and on the misguided concept that people are free to decide their own fate when they lack the capacity to do so and are thus left to fend for themselves when they need to be hospitalized.

While medication is the cornerstone of proper treatment, there are still non evidence based theories being flogged as replacements for the medications. We have Open Dialogue from Finland that lacks any proper evidence, Mental Health First Aid, prevention programs to prevent illnesses where the cause is not known, and to foster peers with so called lived experience to replace trained medical staff. All discussed in this book.

I should also mention that Jaffe talks about the problems that caregivers have dealing with the system because of privacy laws. I quoted him in my Huffington Post blog on the problems that caregivers have with a suggestion that we all deserve a hug.

All of the book is valuable as a resource but what I found most helpful was his Appendix on the studies of Assisted Outpatient Treatment (AOT). These orders compel a mentally ill individual to accept treatment in the community. If they refuse, then they can be hospitalized. Jaffe cites about 20 studies that demonstrate the effectiveness of this program to reduce homelessness, incarceration, violence, reduced hospitalizations, and emergency department visits to name a few.

This book should be mandatory reading for all students in mental health counselling programs, nursing, social work and medicine. It also needs to be read by government policy makers. Money can be thrown at a problem but unless that money is spent wisely on evidence based programs, it is wasted. And that is what happens today.

Multiple personality disorder (MPD) is fiction, is fiction, is fiction. It is not, not, not a bona fide clinical entity, a bona fide human experience, at least it is not a bona fide human experience that occurs on its own, and without the collaboration of an energetic therapist.

I am writing this because I recently ran into two situations involving the ongoing collusion of a believing therapist and a suggestible patient maintaining this fiction, and I watched “Split”, an M. Night Shyamalan horror film featuring MPD and some prodigious acting and special effects. After the embarrassing debunking of MPD by investigative journalists (and a few lawyers) 20 plus years ago, MPD was renamed and diffused (so to speak) as DID, (Dissociative Identity Disorder), which is what it is called in “Split”.

To be conflicted is to be human. To be deeply conflicted is to be a troubled human. To have urges and impulses that are entirely unacceptable to your civilized and socialized self is also human. To say, “I wasn’t myself.” when we find we have done something we should not have done, is also human.

Taking this internal conflict and dramatizing it by embodying each vector in a separate being is a literary technique traceable to the Ancient Greeks, and then famously used by Robert Louis Stevenson in his novella “The Strange Case of Dr. Jekyll and Mr. Hyde” in 1886.

This technique became a natural for film, for mystery and suspense, especially as acting and special effects improved. And then, unfortunately, a psychiatrist wrote a book called “The Three Faces of Eve”, which was made into a very successful film. Multiple Personality became part of popular culture and then migrated to professional culture, adopted by both naïve and excited therapists, and not a few charlatans. How wonderful for therapists to be able to talk directly to those disparate conflicts and impulses, to see them fully fleshed out with voices and names, and not simply talk about them through the filter of the patient’s observing ego. An industry was born. Therapy became theater.

Psychoanalysis is at fault here too, for it assumes a great deal about the integrity of the single human. It ignores the extent to which we are social, interpersonal beings, the extent to which we actually see and experience the world according to the social influences that surround us. The way we answer each and every question according to who is asking and the circumstances of the asking. (Sheldon excepted)

One line among five becomes longer if the others say it is longer. There is a ghost in the building if others say there is a ghost in the building. A sound effect or two and we are convinced. We know the patients of Freudian therapists report Freudian dreams while the patients of Jungian therapists report Jungian dreams. We know it takes a mere ten minutes to convince a child that there is a snake under his bed, a monster in his closet, 20 minutes for an adolescent, and about 60 minutes to convince an adult. We are all impressionable, some more than others. The more uncertain we are of our selves, our reality, our worth, our boundaries, the more malleable we are by social circumstances, other people and therapists, especially intense, believing, well-meaning therapists. Good God, I just read the American Government has spent millions studying ESP, psychics, the paranormal, from bending spoons to cat brains interfering with the electronics of incoming ballistic missiles. Our gullibility has no bounds. Did we learn nothing from that entirely fictitious and therapist manufactured pandemic of Satanic ritual child abuse that swept North America a few years ago?

Our brains do many things to protect us from the harshest, the most painful realities and moments of powerless terror. These include the phenomenon of dissociation (shutting off the experience and going elsewhere in the mind) but one of those things is not concocting a string of alternative identities, a cast of three to fifty, at least not without the encouragement of a colluding and abetting therapist. It may be method acting, but it is still acting. Without an audience it dwindles away.

As I’ve said so many times, anecdotes are not proof of anything but I am going to use one to demonstrate the efficacy of anti-depressants. The anti-medication people do nothing but give anecdotes of the dangers of psychiatric medications and the difficulties some have going off them. When research is cited, they usually attack it as being biased and/or funded by big pharma.

Research does show that for most and when prescribed properly, these pharmaceutical agents do help. As an example, I’m the power of attorney for someone with Alzheimer’s Disease. When he was first being assessed by a family doctor, he came out as being depressed on the Beck Depression Inventory. While he was under going evaluation, he was given anti-depressants which he only took rarely.

However, when he had his diagnosis confirmed by the geriatric psychiatrist, it was recommended that he go back on and stay on the anti-depressant to help with both his depression and his anxiety. In order to ensure compliance with that and the Alzheimer’s med, he was given a weekly blister pack. The pharmacist loaded the pills for each day and for the proper time.

He saw the psychiatrist a few months later and was assessed again on the Mini Mental Status Exam (MMSE). The psychiatrist noted that not only did he appear more relaxed and less anxious than at the previous session, but that his dementia score had improved slightly – not because his dementia was better but because he had less anxiety.

Then, a few months later, the home care co-ordinator showed up to do a reassessment. She called me amazed. My friend, she said, was far more relaxed and showed no signs of anxiety or agitation which were evident when she first assessed him. As she said, “he still does not know where he lives or what the date is, but he is very relaxed about everything”.

Yes, this is an anecdote that and not a definitive study but it is an example of the benefit of this class of drugs. For a list of the meta analytic studies done for anti-depressants that do show efficacy, visit this webpage. Check out the home page on that site for other resources. Thanks to Robert Powitzky for pointing me to it.